HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt #1), clinical records reviewed for complaints and grievances, the Hospital failed to ensure that a voiced complaint was investigated or there was a prompt resolution to the complaint.

Findings include:

1. The Hospital's policy titled, "The Hospital's policy titled, "Patient Complaint" (dated 6/2016), was reviewed, and required, "It is the policy of [Hospital] to provide a means by which patients may voice concerns or complaints regarding their treatment either as -inpatient or an out-patient toward the improvement of service ...The complaint is forwarded to the proper Department or supervisor. A complaint form is completed. The patient is informed that this is being done and that follow-up information will be provided. The problem is investigated, and the situation remedied to the satisfaction of the patient. The results are made known ...When a complaint is received via telephone call from a relative or patient outside the Hospital, the above procedures are also followed and results are made known." Pt #1's husband voiced complaints and there was no formal complaint initiated or resolution/follow-up."

2. The clinical record for Pt #1 was reviewed on 8/21/2023. Pt. #1 was a direct admit to the 3 East Medical/Psychiatric Unit, on 8/24/2022.

- Pt #1's Psychiatric Evaluation Note (dated 8/25/2022 at 3:25 PM), documented by the Psychiatrist MD #1, included " ...long-standing history of major depression, chronic post-traumatic stress disorder, and possibly underlining opioid dependency secondary to primary pain disorder, secondary to the multiple and rather severe chronic and ongoing medical problems ...On day zero, [Pt #1]'s husband contacted the hospital and began to demand that she began receiving treatment ...Today the husband refused to participate in today's family meeting [via phone] because the husband said that he already contacted an administrator and that the administrator was handling things from that point on...The writer had an opportunity to speak with the director of nursing who was able to inform this...The writer informed the administration that they should refer all phone calls all issues and all matters directly to the writer to handle ..."

3. The Hospitals' Complaint/Grievance log (8/2022-8/21/2023), was reviewed. There were no documented complaints or grievances regarding Pt #1.

4. On 8/22/2023 at 11:20 AM, an interview was conducted with the 3 East/3 South Unit Manager (E #8). E #8 stated that when she receives a patient complaint, if it is something that she could not handle, then it is escalated to the Patient Advocate. E #8 stated that she could not recall any incidents or complaints involving Pt #1.

5. On 8/22/2023 at 1:35 PM, an interview was conducted with the Ombudsman/Patient Advocate (E #18). E #18 stated that his department receives complaints from different sources and should resolve them with 2 weeks. E #18 stated that he was not aware of any complaints from Pt #1 or family.

6. On 8/23/2023 at 2:45 PM, an interview was conducted with the Senior Vice President of Patient Care/Chief Nursing Officer (E #1). E #1 stated that nothing was brought to her attention regarding Pt #1's husband complaint, as it should have been. E #1 stated that when this complaint was voiced, it should have been escalated to the Clinical Director and herself.

Based on document review and interview, it was determined that for 1 of 3 (Pt #1) clinical records reviewed for patient rights, the Hospital failed to ensure that a patient's Power of Attorney for Health Care (POAHC), was informed and included in the patient's care, during the hospital course.

Findings include:

1. The Hospital's policy titled, "Patient Rights", dated 12/2009, was reviewed, and required, "[Hospital] is committed to ensuring the preservation of the basic rights of all patients to maintain their independence, privacy, respect and to have access to knowledge for decision-making purposes concerning their health, and to maintain their personal dignity ...To formulate advance directives, such as ...health care power of attorney, and to expect that their advance directives will be followed when applicable ..."

2. The Hospital's policy titled, "Advance Directives" (dated 6/2021), was reviewed, and required, "...There are two types of advance directives authorized by Illinois State: ...Durable Power of Attorney for Health Care and Health Care Agencies...The policy of the hospital is to comply with applicable law and to promote patient self-determination by encouraging the use of advance directives and honoring treatment preferences expressed by patients in their advance directives..."

3. The clinical record for Pt #1 was reviewed on 8/21/2023. Pt. #1 was a direct admit to the 3 East Medical/Psychiatric Unit, on 8/24/2022. Pt #1 was discharged home on 8/27/2022.

- Pt #1's clinical record included a Power of Attorney for Health Care (POAHC), dated 6/30/2022. The form indicated that the patient's husband was the POAHC and, included, "I authorize my agent to: Make decisions for me starting now and continue after I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to ..."

- Pt #1's Psychiatric Notes, from 8/24/2022-8/27/2022, documented by the Psychiatrist (MD #1), included the following on:

- 8/24/2022 at 3:11 PM " ... [Pt #1] was very agitated. Somehow, she got a phone and wanted to continue using it to talk with her husband. Eventually, this led to patient to have a conflict with several of the nurses ...She has a diagnosis of schizoaffective disorder, PTSD [post-traumatic stress syndrome], opioid dependency, and personality disorder ...Although this is day 0 and the patient arrived after the writer left the hospital, the husband wanted to know why haven't the psychiatrist [hasn't been] seeing his wife. The writer elected not to answer specific questions and this seems to anger the husband... The writer instructed the husband that that he was not allowed to contact the hospital staff at all ...The writer will meet with the patient tomorrow but the writer would not have the husband included as part of the treatment team ..."

- 8/25/2022 at 3:25 PM (Psychiatric Evaluation Note), "... The writer does not see any additional benefit from including them [Pt #1's husband and father] as part of the treatment team ...The writer informed the administration that they should refer all phone calls all issues and all matters directly to the writer to handle ..."

- 8/26/2022 at 1:18 PM, "[Pt #1] reports she is doing relatively well. Fortunately, her family only called the hospital on two occasions ..."

4. On 8/21/2023 at 2:15 PM, an interview was conducted with the 3 East Charge RN (E #23). E #23 stated that if a patient has a POA, that POA should be involved with discharge planning and their care overall.

5. On 8/22/2023 at 9:35 AM, an interview was conducted the Psychiatrist (MD #1). MD #1 stated that he had a conversation with Pt #1's husband and stated that the husband was unforgiving. MD #1 stated that Pt #1's husband disagreed with the medical team's treatment plan. MD #1 stated that he put Pt #1's husband on the trespass list and told him that if he comes up to the Hospital, he will call the police, since the husband stated that he was going to take Pt #1 from the hospital.

6. On 8/23/2023 at 2:45 PM, an interview was conducted with the Senior Vice President of Patient Care/Chief Nursing Officer (E #1). E #1 stated that it is not standard practice to ban a spouse or child from involvement with patient care. E #1 stated that she would have personally found a way to communicate with Pt #1's husband. E #1 stated that they don't generally call the police on patients or families. E #1 stated that if there is a need to not involve or prohibit a patient's family, from the Hospital, then this would be a decision from Senior Leadership. E #1 stated that Pt #1's POA should have been involved in the patient's care.